Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brigadier General Wendell H Gilbert Tn State Veter during CMS and state inspections, most recent first.
Incomplete Smoking Care Planning and Monitoring: The facility failed to include smoking in the care plan for one resident with HTN, CKD, and depression, failed to complete quarterly smoking assessments for another resident with COPD and HTN, and did not address smoking in the care plan for a third resident with AKF, DM, and depression. Each resident was identified as a smoker in the record, and all three were observed smoking in the designated smoking area; the DON and MDS Coordinator stated smoking should be addressed in the care plan and that assessments should be completed quarterly.
Failure to follow a physician’s oxygen order for a resident with COPD and SOB. The resident had an order for O2 at 1 LPM via NC, but staff observed him receiving O2 at 2 LPM from both a portable tank and an oxygen concentrator. An LPN confirmed the order was for 1 liter and that the resident was on 2 LPM, and the DON stated the resident should not have been receiving 2 liters when the order was for 1 liter.
Two cognitively impaired residents were left unsupervised, resulting in one resident entering another's room and engaging in inappropriate sexual contact. The incident was witnessed by a CNA, who left to find an LPN rather than immediately intervening, leading to a delay in separating the residents. Both residents had significant cognitive deficits, and the facility's policy required prevention of such abuse, but the residents were not adequately protected.
Incomplete Smoking Care Planning and Monitoring
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for 3 of 21 sampled residents. Facility policy stated that comprehensive care plans are to be individualized and based on information gathered from the MDS, family and resident interviews, and assessments. For one resident admitted with hypertension, chronic kidney disease, and depression, the record showed a Safe Smoking Evaluation dated 4/29/2026 identifying the resident as a smoker and an admission MDS showing a BIMS score of 10, indicating moderate cognitive impairment and tobacco use, but the care plan dated 5/8/2026 did not include smoking. The resident was observed smoking in the designated smoking area on 6/2/2026 at 10:38 AM. For another resident admitted with fusion of spine, COPD, and hypertension, the record showed a Safe Smoking Evaluation dated 12/10/2025 identifying the resident as a smoker and an annual MDS showing a BIMS score of 15, indicating cognitive intactness and tobacco use. The care plan dated 3/23/2026 included a directive to perform a smoking assessment every quarter and PRN, but no smoking assessments were completed after 12/10/2025. The resident was observed smoking in the smoking area on 6/2/2026 at 10:29 AM. For a third resident admitted with acute kidney failure, diabetes, and depression, the record showed multiple Safe Smoking Evaluations identifying the resident as a smoker, including 12/23/2025, 3/25/2026, and 4/19/2026, and an annual MDS showing a BIMS score of 12, indicating moderate cognitive impairment, but tobacco use was not coded and smoking was not addressed in the care plan dated 4/6/2026. The resident was observed on 6/4/2026 at 8:39 AM wearing a fire-retardant apron and smoking a cigarette.
Failure to Follow Physician’s Oxygen Order
Penalty
Summary
The facility failed to follow the physician’s order for oxygen administration for Resident #84, who was admitted with diagnoses including COPD, shortness of breath, and hypertension. The resident’s admission MDS showed a BIMS score of 14, indicating he was cognitively intact. A physician’s order dated 5/19/2026 directed oxygen at 1 LPM via nasal cannula, and the facility policy stated oxygen is to be administered only with a physician’s order and medications are to be administered as prescribed in accordance with written orders. The medical record and observations showed the resident was receiving oxygen at 2 LPM via nasal cannula instead of the ordered 1 LPM. Progress notes documented oxygen saturation readings while the resident was on 2 LPNC, including 93%, 94%, 93%, and 97%. During observation, the resident was seen receiving oxygen from a portable tank at 2 LPM and later from an oxygen concentrator at 2 LPM. When asked, an LPN stated the oxygen was on 2 LPM and confirmed the physician’s order was for 1 liter. The resident stated he did not adjust his oxygen setting. The DON also stated that if the order is for 1 liter, the resident should be receiving 1 liter and not 2 liters.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse, as required by its own policy and federal regulations. The incident involved a resident with severe cognitive impairment, including traumatic brain injury and paranoid schizophrenia, who entered the room of another resident with moderate cognitive impairment and dementia. The first resident was found in bed with the second resident, both unclothed from the waist down, engaging in inappropriate sexual contact. The event was witnessed by a CNA, who left the room to find a nurse, and the nurse subsequently intervened to separate the residents. Medical record reviews indicated that both residents had significant cognitive deficits, with one unable to complete a mental status interview and the other displaying moderate impairment and short-term memory loss. The facility's policy outlined the need to prevent all forms of abuse, including sexual abuse, and to identify residents at increased risk, such as those with confusion or behavioral disturbances. Despite these policies, the residents were left unsupervised, and the incident was not immediately interrupted when first discovered by staff. Camera footage confirmed that the residents remained together and unattended for a period after the inappropriate interaction was witnessed. Interviews with staff revealed that there was no prior history of sexual aggression for either resident, and that staff were aware of the cognitive and behavioral challenges faced by both individuals. The CNA who discovered the incident did not immediately separate the residents but instead left to find a nurse, resulting in a delay. The nurse who responded found both residents unclothed and intervened to remove the first resident from the room. The incident was reported to law enforcement and Adult Protective Services, and both residents were subsequently monitored in separate locations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahava Healthcare Of Clarksville | 7.6 mi | ★★★★★ | 7 | 0 |
| Park Meadows Post Acute | 8.4 mi | ★★★★★ | 6 | 0 |
| Spring Meadows Health And Rehabilitation | 9.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Clarksville | 12.1 mi | ★★★★★ | 0 | 0 |
| Christian Heights Nursing And Rehabilitation Cente | 14.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.